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Mexican Healthcare System Challenges and Opportunities

J A N U A R Y 2 0 1 5

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Mexican Healthcare System Challenges and Opportunities Mexico’s healthcare system is underfunded and

inadequately organized to meet the needs of its

population in light of increasing longevity and the

growing challenges created by the prevalence of

noncommunicable diseases such as diabetes,

obesity, heart disease, and cancer. The

healthcare system has not changed substantially

since the Health Ministry was established in

1943, yet the profile of Mexican patients has

changed dramatically. Coverage has been

expanded since that time and now all Mexicans

have access to basic healthcare services, at

least on paper. Yet the quality of said services,

and in some cases access at all, varies

considerably. Those who can do so rely on

private services to augment, if not replace,

services provided by the state institutions.

The Administration of President Enrique Peña

Nieto, having implemented reforms across a

wide range of sectors such as energy and

telecommunications in the first two years of his

term, is expected to turn to healthcare in 2015,

especially in light of a campaign commitment to

establish a Universal Health System. The

challenges are substantial, but there appears to

be a basic consensus about the changes

required in order to strengthen Mexico’s

healthcare system and to improve its ability to

provide services more appropriate to a

population that is living longer and demanding

better services.

This paper seeks to provide a brief review of the

current system, followed by an analysis of the

potential reforms to be implemented, their pitfalls

and challenges, and finally some suggestions for

where the private sector could contribute to the

reform efforts.

Historically Divided System

Since its inception, coverage under Mexico’s

public healthcare system has been based on

employment status. Salaried or formal-sector

workers are covered under one of two programs.

The Mexican Social Security Institute (Instituto

Mexicano del Seguro Social, or IMSS) was

created in 1943 to provide healthcare coverage

to private-sector, formal, and salaried workers

and their families. In 1959 the Institute of Social

Services and Security for Civil Servants

(Instituto de Seguridad y Servicios Sociales de

los Trabajadores del Estado, or ISSSTE) was

established to provide coverage for government

employees and their families. Nonsalaried or

informal-sector workers were excluded from

formal social insurance schemes and the

healthcare needs of this “residual” group were

addressed by the Ministry of Health. The system

was thus segmented—from its inception and

through to the reform of 2003—between insured,

formal, and salaried employees and their

families with the right to social security, and the

rest of the population (the self-employed,

unemployed, nonsalaried and informal-sector

workers, and those who do not work). The

benefit package for those not covered by IMSS

or ISSSTE was undefined and funded from a

combination of federal funds and, to a lesser

degree, state-level contributions, plus fees paid

by patients and families at the point of service.

Prior to passage of the 2003 health reform

program, approximately 40 percent of the

population was covered by the IMSS, 7 percent

by the ISSSTE, and no more than 2–3 percent

by private health insurance. The remaining 50

percent of the population (roughly 50 million

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people) lacked adequate access to public

healthcare coverage. As a result, insurance

coverage was regressive both among

households and across states, with an

overreliance on out-of-pocket spending to

finance the health system. Further,

impoverishing healthcare spending was

common, particularly among families in the

lowest income deciles.1

In an effort to address the lack of adequate

public healthcare coverage for persons not

covered through a relationship with a formal-

sector worker, President Vicente Fox proposed

legislation that would achieve universal

coverage. The government looked to offer

subsidized, publicly provided health insurance to

the 50 million Mexicans who were not covered

by social security and were concentrated among

the poor. In April 2003 the Congress approved a

new insurance scheme, the Sistema de

Protección Social en Salud (System for Social

Protection in Health or SPSS and commonly

referred to as “Seguro Popular”). The system

went into operation on January 1, 2004 with the

goal of achieving universal coverage by 2010.

The Popular Health Insurance (PHI) was

presented as the operational program of the new

system.

Current System

The healthcare system remains divided, with

coverage based on employment. As noted

above, formal, private-sector employees and

their families are covered by IMSS, whose over

57 million beneficiaries make it one of the

largest insurance providers in the Western

Hemisphere. Public-sector employees and their

families are covered by ISSSTE (roughly

12 million persons). The state oil company

(PEMEX), the armed forces (SEDENA), and the

navy (SEMAR) have their own, smaller,

institutions. The self-employed, unemployed,

nonsalaried and informal-sector workers, and

those who do not work are covered by one of

several federal programs managed by the

Ministry of Health, including the Seguro Popular

program and IMSS-Oportunidades (a federally

funded health service and conditional cash

transfer program), which in total cover roughly

55 million persons. A small number of persons

are eligible for coverage under multiple

institutions, hence the number of beneficiaries

exceeds the national population of 112 million.

The system includes a private-sector component

with insurance companies and service providers

that maintain their own clinics and hospitals,

including providers of alternative medicine.2

Mexico’s Healthcare System3

The quality, scope, and approach to healthcare

vary across the six institutions (IMSS, ISSSTE,

Seguro Popular, PEMEX, SEDENA, and

SEMAR). Each has its own independent network

of doctors, clinics, hospitals, pharmacies,

treatment centers, and unions. (In fact, the labor

union of IMSS, SNTSS, is the second-largest

union in Latin America.) The Mexican healthcare

system does not allow for “portability,” which

means that patients—except those experiencing

obstetric emergencies (as of two years ago)—

cannot access the facilities belonging to any

institution except their own regardless of their

proximity or the relative demand for the service.

In other words, an ISSSTE beneficiary living

next door to an IMSS pharmacy could not fill a

covered prescription at that facility and would

have to travel to the nearest ISSSTE pharmacy

(or pay out of pocket at a retail pharmacy).

Similarly, a kidney dialysis facility belonging to

the Ministry of Health with excess capacity

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cannot treat IMSS patients requiring dialysis

even if the closest IMSS kidney dialysis facility

lacks adequate capacity to treat all of its

patients. The duplication of facilities in some

areas and the shortage of facilities in others is a

result of the independent nature of the systems

and the absence of a single planning

mechanism across the healthcare system. Of

note, the main political parties in Congress have

proposed an expansion of the conditions for

which portability will be permitted to include the

conditions that generate most of the catastrophic

expenses, namely cardiovascular disease,

diabetes, cancer, obesity, transplants, HIV-

AIDS, leukemia, and hemophilia.

Each of the institutions maintains its own drug

and device formularies and develops its own

standards of care, which can vary considerably.

Approvals for drugs and devices for use in

Mexico are granted by the health regulator,

COFEPRIS, which reviews applications to

confirm safety and efficacy for human use.

These approvals apply to all of the institutions—

each can purchase and use anything approved

by COFEPRIS. The decision on whether to

purchase a particular medicine or device,

however, is made through the General Health

Council (CSG). This council is an

interinstitutional body charged with determining

whether the member institutions should

purchase products previously determined by

COFEPRIS to be safe for use in Mexico based

on a cost-benefit analysis. While each of the six

institutions sits on the CSG and reviews the

same information before voting to include or

reject the product, in practice each institution

conducts a second individual review and makes

an independent decision regarding formulary

inclusion. These decisions are often based on

budgetary constraints. The net result, for the

system, is that persons covered by different

(graphic copied from Gómez Dantés et al.)

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institutions have access to different medicines

and devices despite having equal right to access

to healthcare under Article 4 of the Mexican

Constitution.

Peña Nieto’s Reform Plans

During his 2012 campaign, President Enrique

Peña Nieto ran on a platform of instituting

healthcare reform to establish a truly universal

healthcare system that would provide security

and stability for all citizens. The National

Development Plan (Plan Nacional de Desarrollo

2013-2018) and the National Development

Plan’s Program for the Health Sector (Plan

Nacional de Desarollo 2013-2018 – Programa

Sectorial de Salud), both issued in early 2013,

included proposals to emphasize prevention—

rather than focusing only on curative medicine—

and the importance of ensuring that the poorest

of the poor gain access to adequate healthcare.

Specifically, the health program pledged to:

Consolidate protective actions, health

promotion, and disease prevention.

Ensure effective access to quality healthcare.

Reduce the risks affecting health of the

population.

Close existing gaps in health coverage

between different social groups and regions of

the country.

Ensure the generation and effective use of

health resources.

Advance the construction of the National

System of Universal Health under the

stewardship of the Ministry of Health.

Peña Nieto proposed to strengthen the authority

of the Ministry of Health and to promote stronger

cooperation between the state-run medical

programs and private institutions. He favored

strengthening the regulation of healthcare

facilities, implementing stringent quality

standards, supporting the approach of

prevention and promotion of healthy living, and

improving the planning and management of

available resources.

For those living in extreme poverty, Peña Nieto

pledged to intensify training and supervision of

maternal and prenatal caregivers, to augment

vaccination marketing campaigns within poverty-

stricken areas, and to focus on prevention,

diagnosis and treatment of diseases, as well as

a comprehensive strategy for combating

epidemics and malnutrition. The health program

also includes a commitment to the development

and application of a mobile medical units

program, with specific emphasis on vulnerable

areas of Mexico.

The incidence of noncommunicable diseases

(NCDs) has increased in Mexico, and the

country now has one of the highest diabetes

rates in the world. Peña Nieto’s National

Development Plan emphasized promotion of

state-led disease prevention programs, which

could reduce the burden of morbidity and

mortality of chronic noncommunicable diseases,

mainly diabetes and hypertension. Obesity is

another area in which Mexico has the

unfortunate distinction of being a world leader,

even surpassing U.S. rates. This led the Health

Ministry to launch the “National Strategy for the

Prevention and Control of Overweight, Obesity

and Diabetes” in 2013. In addition, heart disease

and cancer rates have also grown—partly as a

result of longer lifespans stemming from

improvements in the quality of life over the past

decades. Average life expectancy has increased

from 70 years in 1990 to 75 years in 2011.4

While increased lifespans are good for

individuals and for society, they do tend to place

additional demands on the healthcare system

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and on its budget. Mexico currently spends

roughly 6.2% of its budget on healthcare, one of

the lowest rates in the OECD and well below the

average of 9.6%.5 This low rate of government

spending places a greater burden on out-of-

pocket expenditure. At present, roughly 45% of

healthcare expenditures in Mexico are paid out

of pocket.6 As a result, long-term illness can be

catastrophic for the lower and even middle

classes.

Reform of the system, therefore, must both

improve the manner in which existing resources

are spent and increase the total amount

available. In addition, and consistent with Peña

Nieto’s National Development Plan, the focus of

healthcare must move from curative treatment to

prevention. There is broad consensus within the

healthcare community in Mexico of these broad

needs; however, to date the government has

taken limited steps to address these objectives.

One concrete proposal related to improving the

health of Mexican citizens was the imposition of

new sales taxes on sugared beverages and

foods considered to be excessively high in

calories (the so-called “junk food” tax), with the

proceeds from the tax to be directed to

improvements in healthcare. The tax proposal

was adopted in December 2013 along with a

number of other tax reform measures; however,

the funds generated were not earmarked for

healthcare. Even if the funds were not directed

toward healthcare, one might have expected

that the tax increase would have led to a

decrease in soda consumption. Recent reports,

however, indicate that consumption has not

declined dramatically.7 Although the reasons for

this are not entirely clear, soft drinks are often

consumed in areas lacking access to clean

water. This suggests that a price increase would

not reduce consumption, but rather shift

consumption to less expensive alternatives such

as local brands or to reductions in other

expenditures. Although early in implementation,

the tax increase has not yet contributed to the

Administration’s stated goal of improving the

health of the population and has created tension

between the private sector and the government.

The Peña Nieto Administration has sought to

improve the efficiency of the drug procurement

process. In October 2014, IMSS coordinated the

“Licitación del Año” or “Sale of the Year” with the

participation of all of the federal healthcare

institutions as well as 17 state health ministries,

by far the largest number to date. Roughly 90

million Mexican citizens were covered by this

reverse auction-style procurement in which

bidders offer steadily lower prices in order to

obtain the contract, with a total expenditure of

$3.7 billion. In addition, IMSS took steps to

guarantee the transparency, competitiveness,

and certainty of the process. It is possible that

continued expansion of the Licitación will

promote greater consistency across the

healthcare system in terms of the availability of

medicines while ensuring the most efficient use

of the drug budget.

An additional healthcare-related initiative

undertaken by the Peña Nieto Administration is

greater promotion of medical tourism, which has

been identified as a priority for ProMexico, the

export promotion/investment attraction arm of

the Secretary of Economy. Mexico receives

medical tourists, primarily from the United

States, who are seeking treatment for conditions

not covered by U.S. insurance—such as

cosmetic surgery, dental procedures, and

weight-loss surgery—or for access to treatments

not approved by the FDA. However, the

government aspires to attract a different type of

patient—one seeking care for conditions that are

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covered by insurance but for which there could

be considerable savings, and considerable

advantages, to having the procedures performed

in Mexico. ProMexico estimates that the cost of

treatment in Mexico can be anywhere from 36%

to 89% less expensive than in the United States

for procedures ranging from dental implants to

heart valve replacement surgery.8 ProMexico

has produced studies that describe the potential

cost savings and identify the hospitals in Mexico

that have received international certifications.

The Secretary of Tourism has also focused

considerable attention on this area; however, it

is unclear to date whether these efforts have

generated increased medical tourism, due to

lingering concerns about public safety and the

overall quality of care.

Earlier this month the chair of the Chamber of

Deputies’ Healthcare Commission announced

that the Peña Nieto Administration will present a

reform proposal when the Congress reconvenes

in February. While the proposal has not yet been

published, public sources suggest it will promote

universal care and institution of “portability”

among the existing institutions.

Challenges to Reform

The divided nature of the Mexican healthcare

system makes reform a daunting task. In

addition to making changes, for example, in the

emphasis from curative to preventative

medicine, reform will require consolidating large

bureaucratic and independent agencies. One of

the initial steps that has often been proposed to

begin a consolidation process is implementation

of “portability,” which would help address the

inefficiencies that have arisen due to the lack of

centralized planning such as a lack of treatment

in some areas and a surplus in others or delays

in gaining access to treatment due to

oversubscription in some areas. Such an

approach could provide an effective means of

evaluating the quality of care between

institutions as well as reducing inefficiencies. If

patients can choose where to have treatment,

then a facility that remains oversubscribed would

indicate a perception (real or imagined) among

patients of higher quality. A facility that is

underutilized, conversely, may need remedial

attention to address perceived (or real)

deficiencies. Nevertheless, portability will not be

easily implemented. There are at least five main

challenges that would have to be addressed to

create an efficient and effective system in which

beneficiaries would be able to choose where

they wanted to be treated.

Reimbursement: Allowing the patient to

choose his or her treatment facility will require

development of a system for interinstitutional

transfers as well as negotiation on the

appropriate rate to be paid for a given service or

procedure. Such a “formulary” would have to

take into account the variations in costs across

the country and the differences in overhead and

other institutional costs. One can imagine, for

example, that IMSS with over 50 million patients

might be able to charge less for some

procedures than the much smaller ISSSTE, or

that the smaller institutions (ISSSTE, SEDENA,

PEMEX) could find it more efficient to outsource

certain treatments and procedures to their larger

counterparts. All of these options would

potentially create efficiencies and greater patient

choice, but none can be adopted quickly.

Rather, the institutions will have to develop a

system to account for the cross-institution (or

“out of network”) treatment that will likely require

initial expenditures to upgrade IT systems and

develop interconnectivity to exchange

information and transfer payments.9

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Health Records: Not only would portability

require the institutions to establish mechanisms

to reimburse for treatment, but they would also

need to exchange patient records in order to

ensure that physicians can properly treat

patients, avoid harmful drug interactions, and

remove the potential for abuses of the system

(such as patients seeking multiple prescriptions).

The development of Health IT systems is

complex and encompasses technological issues

as well as potentially raising patient privacy

concerns. Regrettably, even within the

institutions data collection and retrieval are

limited and inconsistent, and the use of

electronic records rare. Without developing a

comprehensive method of exchanging

information among the institutions, each will

have to rely on patients themselves to provide

information or expend valuable resources

duplicating information already available (in

theory, if not practice) within the patient’s

responsible institution.

Standards of Care: Because the institutions

have developed independently, and have made

independent decisions regarding which

medicines and treatment options to use, the

systems provide different types of care, even for

the same illness. Implementation of portability

will require some sort of reconciliation of, or

training regarding, these differing standards in

order to ensure that beneficiaries of a given

institution can receive equal care regardless of

which institution’s facilities they use. Absent

reconciliation of how a condition should be

treated, reimbursement may be more

complicated among institutions. Further, if a

patient has been treated with a medication or

device not found on another institution’s

formulary, it is possible that the facility would not

be adequately prepared to provide treatment or

not fully appreciate potential drug interactions or

complications related to the use of innovative

devices or medications, especially in the area of

biologics. Harmonization of the technical and

personal quality of health services is one of the

objectives of the National Development Plan,

presumably in recognition of the varying

standards across the healthcare system.

Labor: A fourth major challenge to portability

relates to the employees of the institutions, each

of which negotiates its employment contract

independently. Portability will, in all probability,

drive patients toward or away from certain

facilities. Increases in workload may create labor

strife, while decreases in workload in

underperforming institutions could generate

pressure to reassign personnel to other facilities

or to make other alterations or reductions in

work schedules that the unions may not accept.

In the extreme, portability could even allow for

consolidation and the closing of underutilized

facilities, which, while advantageous from the

perspective of the healthcare system at large,

could simultaneously generate opposition

among local politicians who view delivery of

public facilities as a tangible demonstration of

their contribution to their constituents.

Resources: Simply put, portability will require

initial expenditures from a system that is already

underfunded. Development of integrated

systems to track and manage payments across

the institutions and to permit the exchange of

health records, while ultimately cost-saving, will

initially require new allocations. The differences

of standards of care may require additional

training of personnel to ensure that portability

does not perpetuate differences among

institutions but rather reduces them. While not

the primary focus of this paper, one cannot

review the Mexican healthcare system without

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taking note of the special budgetary challenges

faced by IMSS, which in addition to providing

healthcare services for its beneficiaries also

administers the formal-sector pension system.

Like many other such systems, IMSS faces a

funding shortfall due to comparatively early

retirement eligibility and rising longevity. Since

pensions are guaranteed, IMSS has no choice

but to redirect resources from the healthcare

side of its budget to the pension side. As a

result, IMSS faces an even greater funding

challenge than its counterpart institutions.

Reform of the pension system, including dividing

IMSS into separate institutions with distinct

responsibilities and funding, is one potential

solution, though with its own set of challenges.

Opportunities

Reimbursement and Health IT technology

and implementation. Should the Peña Nieto

Administration decide to embark on an effort to

establish portability, there would be ample

opportunities for private-sector firms to present

offers for services to governmental institutions

related to payment mechanisms and medical

record development and access. For example, it

is unlikely that the current practice of meeting

periodically to reconcile obstetric charges

among the institutions would be adequate to

address the full range of services. Rather, the

institutions will likely need to develop an agreed-

upon electronic solution to provide more timely

reconciliation of what would be a far greater

number of transactions. The back-room

operations required for reconciling claims across

numerous providers and insurance companies in

the United States will have led to development

of important efficiencies and economies of scale

that may be replicable in Mexico. On the

electronic records side, and as noted previously,

portability will require enhanced collection and

sharing of electronic patient records that will

raise similar concerns to those identified in the

United States. Solutions providers that can help

healthcare providers protect sensitive

information while ensuring real-time access

across the institutions may find a number of

interested customers that will be responding to

patient demand for privacy.

Medical tourism. The dramatic cost

differences for some procedures between

Mexico and the United States and the emphasis

on rehabilitative care following surgery give

Mexico important comparative advantages over

the United States. In addition, as the Affordable

Care Act is implemented, an increasing number

of employers will seek affordable options for

employee healthcare. A medical tourism

program developed in partnership between an

insurer, an employer, and a Mexican hospital

could prove to be an effective way to ensure

adequate, affordable treatment. In addition, such

a program can provide important training and

capacity building for the Mexican institution—

experience that can then be made available to

Mexican patients as well as foreigners. Two

major impediments to increased medical tourism

in Mexico are concerns over public safety (not

limited to medical tourism, of course) and

concerns regarding assurances of quality of care

in Mexico and then following return to the United

States. Increasing the consistency of quality of

care among Mexican hospitals, perhaps through

partnerships with U.S. teaching hospitals, and/or

providing guidance on how to meet international

standards where desired or appropriate are two

additional areas that could generate

opportunities and produce positive benefits for

all parties.

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Creative procurement. Combined

purchasing across the institutions, such as

through the “Licitación del Año,” with its reverse-

auction format, can be an effective means to

exploit economies of scale. If combined with

efforts to standardize care across institutions,

this approach should make an important

contribution toward equal care for all Mexicans

regardless of the source of their income. From

the perspective of producers and distributors of

these products, the combined purchase will

necessitate more creative bids, including risk

sharing and perhaps integrated approaches that

combine product and delivery. It is important to

note, however, that most of the funds dedicated

to the Licitación were used to purchase generic

medicines. As a result, Mexican patients relying

on the state will continue to be denied access to

the innovative medicines and devices that have

been approved by COFEPRIS in the past few

years. Ideally, the Mexican government would

use some of the savings generated by the

combined purchase of basic medicines to create

space in the budget for innovative devices and

medicines that could, in the long run, prove

more cost-effective.

Regulatory convergence. The National

Development Plan calls for the promotion of

international health cooperation. The President

seeks to strengthen surveillance of

epidemiological emergencies, comply with

international treaties on human health rights

framework, and encourage new patterns of

international cooperation in public health to

strengthen local and regional capacity. While

much of this remains rhetorical, the Peña Nieto

Administration, under the leadership of

COFEPRIS Federal Commissioner Mikel Arriola,

has embarked on an effort within the Pacific

Alliance (PA) to establish a common regulatory

system among the four member countries

(Mexico, Colombia, Peru, and Chile). As this

effort reaches full implementation, it will create a

single market of roughly 200 million people. If

the agreed regulations match international

standards and best practices, the result should

be more rapid introduction of new, innovative

technologies into Mexico and its fellow PA

members. While not directly related to

healthcare reform in Mexico, efforts to bring

more innovation to Mexico more quickly will

directly impact the efficiency of the healthcare

budget.

Conclusion

The fractured Mexican healthcare system

provides treatment for roughly 110 million

patients who are living longer and will continue

to demand better care as their country continues

to grow economically. The current divided

system is inadequate to both address the

growing needs and effectively respond to

changes in the demographic composition of the

country. Mexico is currently in the advantageous

demographic bubble when its working

population exceeds the size of the nonworking

population. This moment in the demographic

timeline is the ideal time to make systemic

changes that can proactively anticipate the

needs of the future population. Doing so will

require the kind of political leadership and

national consensus seen in the recent reform of

the energy sector. When the Peña Nieto

Administration embarks on reform, the

opportunities for public-private partnerships and

foreign investment and participation will be

considerable, particularly for companies with

appropriate guidance and a willingness to

explore innovative approaches.

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About ManattJones Global Strategies, LLC

ManattJones provides strategic business advice and advocacy to companies operating in, investing in, or exporting to Mexico and Latin America. The firm helps clients identify and take advantage of opportunities and address strategic, political, and market access challenges. With many years of experience, we offer unmatched market knowledge, extensive regional experience, and a deep network of relationships with senior business, government and civic leaders. The firm has assisted both large and midsized companies to do business in and with Mexico across a wide range of sectors.

ManattJones is a consulting subsidiary of Manatt, Phelps & Phillips, LLP, a leading United States-based law firm, and has offices in Washington, D.C., Los Angeles, Mexico City and Monterrey. For more information, visit www.manattjones.com.

For more information, contact:

Michael C. Camuñez President and CEO 1.310.312.4180 mcamunez@manatt.com Los Angeles, CA Washington, D.C.

Ambassador James R. Jones Chairman 1.202.585.6560 jjones@manattjones.com Washington, D.C.

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1 Ministry of Health, Programa Nacional de Salud 2001–2006: La democratización de la salud en México, hacia un sistema universal de salud (Mexico City: Ministry of Health, 2001); Ministry of Health, Salud: México 2001. Información para la rendición de cuentas (Mexico City: Ministry of Health, 2002); and J. Frenk et al., “Fair Financing and Universal Social Protection: The Structural Reform of the Mexican Health System,” working paper (Mexico City: Ministry of Health, 2004).

2 Gómez Dantés, Octavio, Sergio Sesma, Victor Becerril, Felicia Knaul, Héctor Arreola, and Julio Frenk. “Articulo De Revision.” Salud Pública De México. N.p., 2011. Web. <http://bvs.insp.mx/rsp/articulos/articulo_e4.php?id=002625>.

3 Gómez Dantés et al.

4 “Health Profile: Mexico.” World Health Rankings. World Life Expectancy, n.d. Web. <http://www.worldlifeexpectancy.com/country-health-profile/mexico>.

5 Study conducted by IMS Health for the Asociacion Mexicana de Industrias de Investigacion Farmaceutica (AMIIF), January 2014.

6 Instituto Nacional De Estadistica Y Geografia. “Cuenta Satelite Del Sector Salud De Mexico, 2012.” Boletin De Prensa 256/14 (n.d.): n. pag. 5 June 2014. Web. <http://www.inegi.org.mx/inegi/contenidos/espanol/prensa/boletines/boletin/comunicados/especiales/2014/junio/comunica1.pdf>

7 “Survey Shows Mexicans Drinking Less Soda After Tax; Majority of Participants Now Relating Sugary Drinks to Health Problems,” Wall Street Journal (WSJ.com edition), October 13, 2014.

8 “Health Tourism,” 2013 report prepared by ProMexico.

9 It should be noted that the institutions already meet periodically to reconcile accounts for treatment of obstetric emergencies based on a fixed cost per treatment according to Under-Secretary of Health Eduardo Gonzalez-Pier (interview published in El Universal, September 1, 2014).

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